Provider Demographics
NPI:1780736215
Name:SMITH, FRED L (DC)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 OAK ST
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1340
Mailing Address - Country:US
Mailing Address - Phone:618-382-4834
Mailing Address - Fax:618-382-7129
Practice Address - Street 1:908 OAK ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1340
Practice Address - Country:US
Practice Address - Phone:618-382-4834
Practice Address - Fax:618-382-7129
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003396111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038003396Medicaid
IL295740Medicare ID - Type Unspecified
IL038003396Medicaid